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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> -FA 0 U <br /> OWNER/OP RATOR <br /> r��i,w^ Cn 1 1^ ) CHECK if BILLING ADDRESS <br /> i <br /> FACILITY NAME <br /> SITE ADDRESS g p � 0� y Sz O C{ <br /> Street Number Direction Street Name C 1 Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Addre s) /►/� Jag <br /> 3 Street Number 6� 1 Street Name <br /> CITY S E ZIP <br /> C 9 5307 <br /> PHONE#1 EXT. ApN# LAND USE APPLICATION# <br /> (yIy) 551 0530 <br /> PHONE ill EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> re S i 41 <br /> HOME or MAILING ADDRESS FAX# <br /> So VvW& <br /> CITY J 'tcx Ii i� STATE C ZIP CIS 2G tY <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated With this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST E and FEDERAL laws. <br /> S2 -A <br /> APPLICANT'S SIGNATURE: DATE: 6 <br /> PROPERTY/BUSINESS OWNER C5- OPERATOR/MANAGER ❑ OTHER AU HORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property to �j at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site ass-e �l1 tion <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It vf�ii rot <br /> my representative. cc '/ <br /> TYPE OF SERVICE REQUESTED: 4a-v C'z2n G� d N , <br /> JU <br /> COMMENTS: <br /> FNVIR QU/N CO <br /> HE'gLTy PAR 17AL <br /> ACCEPTED BY: EMPLOYEE#: ) DATE: / I <br /> ASSIGNED TO: EMPLOYEE#: lJ DATE: , <br /> Date Service Completed (if already completed): SERVICE CODE: 1 PIE: <br /> Fee Amount: 1�, G Amount Pal S� Payment Date <br /> �12Payment Type Invoice# Check# q.251a4 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />